Life in the buffer zone: Social relations and surplus health workers in Uganda's medicines retail sector

From humanitarian crisis to employment crisis: The lives and livelihoods of South Sudanese refugee health workers in Uganda

Despite the many benefits of refugee health workers for health systems, they commonly face challenges integrating into host country workforces. The Global Code of Practice on International Recruitment of Health Personnel, which should monitor and protect migrant health workers, offers little guidance for refugees and research is needed to inform strategy. Based on interviews with 34 refugee health workers and 10 leaders across two settlements supporting populations fleeing the humanitarian crisis in South Sudan since 2013, we describe the governance and social dynamics affecting South Sudanese refugee health worker employment in Uganda. Refugees in Uganda legally have the right to work but face an employment crisis. Refugee health workers report that systemic discrimination, competition from underemployed domestic workers, unclear work permit rules and expensive credentialling processes exclude them from meaningful work in public health facilities and good jobs in the humanitarian response. This pushes them into unchallenging roles in private clinics, poorly remunerated positions on village health teams or out of the health sector altogether. Health system strengthening initiatives in Uganda to integrate humanitarian and government services and to deter the domestic workforce from emigration have overlooked the potential contributions of refugee health workers and the employment crisis they face. More effort is needed to increase fairness in public sector recruitment practices for refugee health workers, support credentialling, training opportunities for professional and non-professional cadres, job placements, and to draw attention to the public benefits of refugee health worker employment alongside higher spending on human resources for health.

The paradoxical surplus of health workers in Africa: The need for research and policy engagement

In many countries in Africa, there is a 'paradoxical surplus' of under and unemployed nurses, midwives, doctors and pharmacists which exists amidst a shortage of staff within the formal health system. By 2030, the World Health Organisation Africa Region may find itself with a shortage of 6.1 million health workers alongside 700,000 un- or underemployed health staff. The emphasis in policy debates about human resources for health at most national and global levels is on staff shortage and the need to train more health workers. In contrast, these 'surplus' health workers are both understudied and underacknowledged. Little time is given over to understand the economic, political and social factors that have driven their emergence; the ways in which they seek to make a living; the governance challenges that they raise; nor potential interventions that could be implemented to improve employment rates and leverage their expertise. This short communication reflects on current research findings and calls for improved quantitative and qualitative research to support policy engagement at national, regional and global levels.

Unsalaried health workers in Sierra Leone: a scoping review of the literature to establish their impact on healthcare delivery

BACKGROUND

The World Health Organisation (WHO) estimates a 10 million health worker shortage by 2030. Despite this shortage, some low-income African countries paradoxically struggle with health worker surpluses. Technically, these health workers are needed to meet the minimum health worker-population ratio, but insufficient job opportunities in the public and private sector leaves available health workers unemployed. This results in emigration and un- or underemployment, as few countries have policies or plans in place to absorb this excess capacity. Sierra Leone, Liberia and Guinea have taken a different approach; health authorities and/or public hospitals 'recruit' medical and nursing graduates on an unsalaried basis, promising eventual paid public employment. 50% Sierra Leone's health workforce is currently unsalaried. This scoping review examines the existing evidence on Sierra Leone's unsalaried health workers (UHWs) to establish what impact they have on the equitable delivery of care.

METHODS

A scoping review was conducted using Joanna Briggs Institute guidance. Medline, PubMed, Scopus, Web of Science were searched to identify relevant literature. Grey literature (reports) and Ministry of Health and Sanitation policy documents were also included.

RESULTS

36 texts, containing UHW related data, met the inclusion criteria. The findings divide into two categories and nine sub-categories: Charging for care and medicines that should be free; Trust and mistrust; Accountability; Informal provision of care, Private practice and lack of regulation. Over-production of health workers; UHW issues within policy and strategy; Lack of personnel data undermines MoHS planning; Health sector finance.

CONCLUSION

Sierra Leone's example demonstrates that UHWs undermine equitable access to healthcare, if they resort to employing a range of coping strategies to survive financially, which some do. Their impact is wide ranging and will undermine Sierra Leone's efforts to achieve Universal Health Coverage if unaddressed. These findings are relevant to other LICs with similar health worker surpluses.

Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda

The medicines retail sector is an essential element of many health systems in Africa and Asia, but it is also well known for poor practice. In the literature, it is recognised that improvements in the sector can only be made if more effective forms of governance and regulation can be identified. Recent debate suggests that interventions responsive to structural constraints that shape and underpin poor practice is a useful way forward. This paper presents data from a mixed-methods study conducted to explore regulation and the professional, economic and social constraints that shape rule breaking among drug shops in one district in Uganda. Our findings show that regulatory systems are undermined by frequent informal payments, and that although drug shops are often run by qualified staff, many are unlicensed and sell medicines beyond their legal permits. Most shops have either a small profit or a loss and rely on family and friends for additional resources as they compete in a highly saturated market. We argue that in the current context, drug shop vendors are survivalist entrepreneurs operating in a market in which it is extremely difficult to abide by policy, remain profitable and provide a service to the community. Structural changes in the medicines market, including removing unqualified sellers and making adjustments to policy are likely prerequisite if drug shops are to become places where individuals can earn a living, abide by the rules and facilitate access to medicines for people living in some of the world's poorest countries.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

BACKGROUND

Lack of political will is frequently invoked as a rhetorical tool to explain the gap between commitment and action for health reforms in sub-Saharan Africa (SSA). However, the concept remains vague, ill defined and risks being used as a scapegoat to actually examine what shapes reforms in a given context, and what to do about it. This study sought to go beyond the rhetoric of political will to gain a deeper understanding of what drives health reforms in SSA.

METHODS

We conducted a scoping review using Arksey and O'Malley (2005) to understand the drivers of health reforms in SSA.

RESULTS

We reviewed 84 published papers that focused on the politics of health reforms in SSA covering the period 2002-2022. Out of these, more than half of the papers covered aspects related to health financing, HIV/AIDS and maternal health with a dominant focus on policy agenda setting and formulation. We found that health reforms in SSA are influenced by six; often interconnected drivers namely (1) the distribution of costs and benefits arising from policy reforms; (2) the form and expression of power among actors; (3) the desire to win or stay in government; (4) political ideologies; (5) elite interests and (6) policy diffusion.

CONCLUSION

Political will is relevant but insufficient to drive health reform in SSA. A framework of differential reform politics that considers how the power and beliefs of policy elites is likely to shape policies within a given context can be useful in guiding future policy analysis.